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Ghoneima AS, Sousa Da Silva RX, Gosteli MA, Barlow AD, Kron P. Outcomes of Kidney Perfusion Techniques in Transplantation from Deceased Donors: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:3871. [PMID: 37373568 DOI: 10.3390/jcm12123871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/03/2023] [Accepted: 05/09/2023] [Indexed: 06/29/2023] Open
Abstract
The high demand for organs in kidney transplantation and the expansion of the donor pool have led to the widespread implementation of machine perfusion technologies. In this study, we aim to provide an up-to-date systematic review of the developments in this expanding field over the past 10 years, with the aim of answering the question: "which perfusion technique is the most promising technique in kidney transplantation?" A systematic review of the literature related to machine perfusion in kidney transplantation was performed. The primary outcome measure was delayed graft function (DGF), and secondary outcomes included rates of rejection, graft survival, and patient survival rates after 1 year. Based on the available data, a meta-analysis was performed. The results were compared with data from static cold storage, which is still the standard of care in many centers worldwide. A total of 56 studies conducted in humans were included, and 43 studies reported outcomes of hypothermic machine perfusion (HMP), with a DGF rate of 26.4%. A meta-analysis of 16 studies showed significantly lower DGF rates in the HMP group compared to those of static cold storage (SCS). Five studies reported outcomes of hypothermic machine perfusion + O2, with an overall DGF rate of 29.7%. Two studies explored normothermic machine perfusion (NMP). These were pilot studies, designed to assess the feasibility of this perfusion approach in the clinical setting. Six studies reported outcomes of normothermic regional perfusion (NRP). The overall incidence of DGF was 71.5%, as it was primarily used in uncontrolled DCD (Maastricht category I-II). Three studies comparing NRP to in situ cold perfusion showed a significantly lower rate of DGF with NRP. The systematic review and meta-analysis provide evidence that dynamic preservation strategies can improve outcomes following kidney transplantation. More recent approaches such as normothermic machine perfusion and hypothermic machine perfusion + O2 do show promising results but need further results from the clinical setting. This study shows that the implementation of perfusion strategies could play an important role in safely expanding the donor pool.
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Affiliation(s)
- Ahmed S Ghoneima
- Department of HPB and Transplant Surgery, St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
| | - Richard X Sousa Da Silva
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland
| | | | - Adam D Barlow
- Department of HPB and Transplant Surgery, St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
| | - Philipp Kron
- Department of HPB and Transplant Surgery, St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland
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Olausson M, Antony D, Travnikova G, Johansson M, Nayakawde NB, Banerjee D, Søfteland JM, Premaratne GU. Novel Ex-Vivo Thrombolytic Reconditioning of Kidneys Retrieved 4 to 5 Hours After Circulatory Death. Transplantation 2022; 106:1577-1588. [PMID: 34974455 PMCID: PMC9311461 DOI: 10.1097/tp.0000000000004037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Due to organ shortage, many patients do not receive donor organs. The present novel thrombolytic technique utilizes organs from donors with uncontrolled donation after circulatory deaths (uDCD), with up to 4-5 h warm ischemia, without advanced cardiopulmonary resuscitation (aCPR) or extracorporeal circulation (EC) after death. METHODS The study group of pigs (n = 21) underwent simulated circulatory death. After 2 h, an ice slush was inserted into the abdomen. Kidneys were retrieved 4.5 h after death. Lys-plasminogen, antithrombin-III (ATIII), and alteplase (tPA) were injected through the renal arteries on the back table. Subsequent ex vivo perfusion at 15 °C was continued for 3 h, followed by 3 h with red blood cells (RBCs) at 32 °C. Perfusion outcome and histology were compared between uDCD kidneys, receiving no thrombolytic treatment (n = 8), and live donor kidneys (n = 7). The study kidneys were then transplanted into pigs as autologous grafts with a single functioning autologous kidney as the only renal support. uDCD control pigs (n = 8), receiving no ex vivo perfusion, served as controls. RESULTS Vascular resistance decreased to <200 mmHg/mL/min ( P < 0.0023) and arterial flow increased to >100 mL/100 g/min ( P < 0.00019) compared to controls. In total 13/21 study pigs survived for >10 days, while all uDCD control pigs died. Histology was preserved after reconditioning, and the creatinine level after 10 days was next to normal. CONCLUSIONS Kidneys from extended uDCD, not receiving aCPR/EC, can be salvaged using thrombolytic treatment to remove fibrin thrombi while preserving histology and enabling transplantation with a clinically acceptable early function.
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Affiliation(s)
- Michael Olausson
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Deepti Antony
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Galina Travnikova
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Martin Johansson
- Department of Laboratory Medicine, Sahlgrenska Academy, University of Gothenburg, SE-41345 Göteborg, Sweden
| | - Nikhil B. Nayakawde
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Debashish Banerjee
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - John Mackay Søfteland
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Goditha U. Premaratne
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
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Tatsis V, Dounousi E, Mitsis M. Hypothermic Machine Perfusion of Kidney Transplant: A Mini-Review. Transplant Proc 2021; 53:2793-2796. [PMID: 34696905 DOI: 10.1016/j.transproceed.2021.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Most kidney grafts are marginal and from deceased donors, which yield worse clinical outcomes. Hypothermic machine perfusion has created a paradigm shift in kidney preservation. This mini-review summarizes the main points of hypothermic machine perfusion of kidney transplants that should be known by any physician and surgeon involved with kidney transplantation. Specifically, this review explains a proposed mechanism of action of hypothermic machine perfusion of kidney transplants. This review also describes the clinical effectiveness of hypothermic machine perfusion and explains how to evaluate and predict graft functionality according to machine parameters and perfusate biomarkers. Finally, treatment options and the most recent studies on oxygenated hypothermic machine perfusion are mentioned.
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Affiliation(s)
| | - Evangelia Dounousi
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
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Peris A, Fulceri GE, Lazzeri C, Bonizzoli M, Li Marzi V, Serni S, Cirami L, Migliaccio ML. Delayed graft function and perfusion parameters of kidneys from uncontrolled donors after circulatory death. Perfusion 2020; 36:299-304. [PMID: 32650710 DOI: 10.1177/0267659120938928] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Better preservation and evaluation of kidneys from donors after circulatory death serve to increase the number of kidneys available for transplantation and hypothermic machine perfusion has been shown to decrease ischemia reperfusion injury and delayed graft function. Data on relation between hemodynamic parameters during hypothermic machine perfusion and delayed graft function in kidneys from donors after circulatory death are so far scarce and not univocal. We aimed at assessing whether hemodynamic parameters measured during hypothermic machine perfusion (flow, mean perfusion pressure, and renal resistance) are associated with delayed graft function in 26 kidneys retrieved from uncontrolled donors after circulatory death. In our series, the incidence of delayed graft function was 57.7% (15/26). Recipients who developed delayed graft function had a longer warm ischemic time (p = 0.04). All hemodynamic parameters measured during hypothermic machine perfusion were comparable between recipients with delayed graft function and those without. According to our data, in kidneys from uncontrolled donors after circulatory death, a longer warm ischemic time (that is the overall time of no flow, as the sum of the no-flow and the no-touch period) is associated with delayed graft function. This finding underscores the pivotal role of ischemic injury in terms of absence of flow in affecting graft function. No association was detectable between hemodynamic parameters during hypothermic machine perfusion and the development of delayed graft function in our series.
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Affiliation(s)
- Adriano Peris
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giorgio Enzo Fulceri
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Chiara Lazzeri
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Manuela Bonizzoli
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Vincenzo Li Marzi
- Department of Urological Robotic Surgery and Kidney Transplantation, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Sergio Serni
- Department of Urological Robotic Surgery and Kidney Transplantation, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Lino Cirami
- Department of Nephrology, University of Florence, Careggi Hospital, Florence, Italy
| | - Maria Luisa Migliaccio
- Tuscany Authority for Transplantation (Centro Regionale Allocazione Organi e Tessuti CRAOT), Florence, Italy
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Ding CG, Tian PX, Ding XM, Xiang HL, Li Y, Tian XH, Han F, Tai QH, Liu QL, Zheng J, Xue WJ. Beneficial Effect of Moderately Increasing Hypothermic Machine Perfusion Pressure on Donor after Cardiac Death Renal Transplantation. Chin Med J (Engl) 2019; 131:2676-2682. [PMID: 30425194 PMCID: PMC6247599 DOI: 10.4103/0366-6999.245274] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: Vascular resistance and flow rate during hypothermic machine perfusion (HMP) of kidneys is correlated with graft function. We aimed to determine the effects of increasing HMP pressure versus maintaining the initial pressure on kidney transplantation outcomes. Methods: We retrospectively reviewed the data of 76 primary transplantation patients who received HMP-preserved kidneys from 48 donors after cardiac death between September 1, 2013, and August 31, 2015. HMP pressure was increased from 30 to 40 mmHg (1 mmHg = 0.133 kPa) in kidneys with poor flow and/or vascular resistance (increased pressure [IP] group; 36 patients); otherwise, the initial pressure was maintained (constant pressure group; 40 patients). Finally, the clinical characteristics and transplantation outcomes in both groups were assessed. Results: Delayed graft function (DGF) incidence, 1-year allograft, patient survival, kidney function recovery time, and serum creatinine level on day 30 were similar in both groups, with improved flow and resistance in the IP group. Among patients with DGF, kidney function recovery time and DGF duration were ameliorated in the IP group. Multivariate logistic regression analysis revealed that donor hypertension (odds ratio [OR]: 1.43, 95% confidence interval [CI]: 1.02–2.06, P = 0.035), donor terminal serum creatinine (OR: 1.27, 95% CI: 1.06–1.62, P = 0.023), warm ischemic time (OR: 3.45, 95% CI: 1.97–6.37, P = 0.002), and terminal resistance (OR: 3.12, 95% CI: 1.76–6.09, P = 0.012) were independent predictors of DGF. Cox proportional hazards analysis showed that terminal resistance (hazard ratio: 2.06, 95% CI: 1.32–5.16, P = 0.032) significantly affected graft survival. Conclusion: Increased HMP pressure improves graft perfusion but does not affect DGF incidence or 1-year graft survival.
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Affiliation(s)
- Chen-Guang Ding
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University; Institute of Organ Transplantation, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Pu-Xun Tian
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University; Institute of Organ Transplantation, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Xiao-Ming Ding
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University; Institute of Organ Transplantation, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - He-Li Xiang
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University; Institute of Organ Transplantation, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Yang Li
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University; Institute of Organ Transplantation, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Xiao-Hui Tian
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University; Institute of Organ Transplantation, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Feng Han
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University; Institute of Organ Transplantation, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Qian-Hui Tai
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University; Institute of Organ Transplantation, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Qian-Long Liu
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University; Institute of Organ Transplantation, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Jin Zheng
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University; Institute of Organ Transplantation, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Wu-Jun Xue
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University; Institute of Organ Transplantation, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
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Sandal S, Paraskevas S, Cantarovich M, Baran D, Chaudhury P, Tchervenkov JI, Sapir-Pichhadze R. Renal resistance thresholds during hypothermic machine perfusion and transplantation outcomes - a retrospective cohort study. Transpl Int 2018; 31:658-669. [PMID: 29493843 DOI: 10.1111/tri.13146] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 09/06/2017] [Accepted: 02/21/2018] [Indexed: 12/31/2022]
Abstract
Renal resistance (RR), of allografts undergoing hypothermic machine perfusion (HMP), is considered a measure of organ quality. We conducted a retrospective cohort study of adult deceased donor kidney transplant (KT) recipients whose grafts underwent HMP. Our aim was to evaluate whether RR is predictive of death-censored graft failure (DCGF). Of 274 KT eligible for analysis, 59% were from expanded criteria donor. RR was modeled as a categorical variable, using a previously identified terminal threshold of 0.4, and 0.2 mmHg/ml/min (median in our cohort). Hazard ratios (HR) of DCGF were 3.23 [95% confidence interval (CI): 1.12-9.34, P = 0.03] and 2.67 [95% CI: 1.14-6.31, P = 0.02] in univariable models, and 2.67 [95% CI: 0.91-7.86, P = 0.07] and 2.42 [95% CI: 1.02-5.72, P = 0.04] in multivariable models, when RR threshold was 0.4 and 0.2, respectively. Increasing risk of DCGF was observed when RR over the course of HMP was modeled using mixed linear regression models: HR of 1.31 [95% CI: 1.07-1.59, P < 0.01] and 1.25 [95% CI: 1.00-1.55, P = 0.05], in univariable and multivariable models, respectively. This suggests that RR during HMP is a predictor of long-term KT outcomes. Prospective studies are needed to assess the survival benefit of patients receiving KT with higher RR in comparison with staying wait-listed.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC, Canada
| | - Steven Paraskevas
- Division of General Surgery and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC, Canada
| | - Marcelo Cantarovich
- Division of Nephrology and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC, Canada
| | - Dana Baran
- Division of Nephrology and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC, Canada
| | - Prosanto Chaudhury
- Division of General Surgery and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC, Canada
| | - Jean I Tchervenkov
- Division of General Surgery and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC, Canada
| | - Ruth Sapir-Pichhadze
- Division of Nephrology and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC, Canada.,Division of Clinical Epidemiology, McGill University Health Centre, Montreal, QC, Canada.,Centre for Outcomes Research and Evaluation (CORE), McGill University Health Centre, Montreal, QC, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
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Perfusion Parameters of Donation After Cardiac Death Kidneys Predict Early Transplant Outcomes Based on Expanded Criteria Donor Designation. Transplant Proc 2018; 50:79-84. [DOI: 10.1016/j.transproceed.2017.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 11/03/2017] [Indexed: 11/23/2022]
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Abstract
BACKGROUND Kidney donation after cardiac death leads to vascular damage as a result of warm ischemia, affecting renovascular circulating volume. Novel ultrasound dilution techniques may be used to measure renovascular circulating volumes during hypothermic machine perfusion of donor kidneys. METHODS Renovascular circulating volumes of machine-perfused porcine kidneys were repeatedly measured by ultrasound dilution at different perfusion pressures (30, 40, 50, and 60 mm Hg), durations of perfusion (1 and 24 hr), and warm ischemia times (15 and 45 min). Validity of ultrasound dilution was assessed by comparing volume changes after clamping of renal artery branches. RESULTS Repeatability of ultrasound dilution measurements of renovascular circulating volumes was good (mean coefficient of variation, 7.6%). Renovascular circulating volumes significantly increased with higher perfusion pressures, remained constant over time, and significantly decreased with longer warm ischemia times. Changes in ultrasound dilution measurements after renal artery branch clamping did not correlate with changes in actual perfused volumes. CONCLUSIONS Ultrasound dilution is a reproducible method to assess renovascular circulating volumes in machine-perfused kidneys, which is susceptible to changes in warm ischemia times. Future studies should evaluate the value of renovascular volume in pretransplantation kidney viability testing.
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Abstract
PURPOSE OF REVIEW Pretransplant assessment of kidney graft viability may help clinicians to decide whether to accept or discard a kidney for transplantation. With the increasing demand for donor kidneys and the increased use of marginal kidneys, the need of viability markers has increased to pursue superior transplant outcomes. Hypothermic machine perfusion (HMP) provides the theoretical opportunity to assess the viability of donor kidneys. We discuss the novel developments in viability testing during HMP and address the future prospects. RECENT FINDINGS HMP viability testing has focused on the analysis of machine perfusion parameters and perfusate biomarkers. Renal resistance and the biomarkers lactate dehydrogenase, aspartate transaminase, glutathione-S-transferase, N-acetyl-β-D-glucosaminidase, heart-type fatty acid binding protein, lipid peroxidation products, redox-active iron and IL-18 are correlated with transplant outcome in terms of development of delayed graft function or graft survival. However, they all lack adequate predictive value for transplant outcome. New techniques including contrast-enhanced ultrasound, three-dimensional ultrasound and magnetic resonance spectrometry are promising methods to test kidney viability during HMP, but their value has to be established. The introduction of normothermic machine perfusion offers other promising opportunities for viability testing. SUMMARY Machine perfusion characteristics and perfusate biomarkers have been extensively studied. They often correlate with the transplant outcome, but the present viability tests are not reliable predictors of transplant outcome. New developments in kidney graft viability assessment are necessary to have a chance of being clinically useful in the future.
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